Statement of Marital Relationship

ICR 201103-2900-008

OMB: 2900-0114

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2011-06-14
IC Document Collections
IC ID
Document
Title
Status
28314 Modified
ICR Details
2900-0114 201103-2900-008
Historical Active 200709-2900-016
VA 2900-0114
Statement of Marital Relationship
Extension without change of a currently approved collection   No
Regular
Approved without change 09/05/2011
Retrieve Notice of Action (NOA) 07/18/2011
  Inventory as of this Action Requested Previously Approved
09/30/2014 36 Months From Approved 09/30/2011
6,500 0 6,500
2,708 0 2,708
0 0 0

VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

US Code: 38 USC 103(c) Name of Law: Special provisions relating to marriages.
   US Code: 38 USC 101(3) and 101(31) Name of Law: Definitions
  
None

Not associated with rulemaking

  76 FR 58 03/25/2011
76 FR 109 06/07/2011
No

1
IC Title Form No. Form Name
Statement of Marital Relationship 21-4170 Statement of Marital Relationship

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 6,500 6,500 0 0 0 0
Annual Time Burden (Hours) 2,708 2,708 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$107,262
No
No
No
No
No
Uncollected
Denise McLamb 202-565-8374 denise.mclamb@mail.va.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/18/2011


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